MA Expert Panel on End of Life Report

Transcription

1 University of Massachusetts Medical School MA Expert Panel on End of Life Report Looking Forward: 2014 and Beyond Presented by: UMass Medical School 333 South Street Shrewsbury, MA

2 Table of Contents 1. Executive Summary....page 2 2. Introduction...page 4 3. Massachusetts 2014 End of Life Summit Action Plan...page 6 4. Massachusetts End of Life Expert Panel Report 2014 Update: Recommended Next Steps....page Appendices... page a. MA End of Life Summit Participants....page 18 b. Description of Process to Update 2010 Expert Panel Report... page 19 c. Results of Process to Update 2010 Expert Panel Report... page 21 d. MOLST Statewide Expansion... page 26 e. MOLST Evaluation Report Executive Summary... page 27 f. MOLST Committee Membership... page 28 g. End of Life/Palliative Care Policy-Related Activities in Massachusetts and Other States... page 30 The University of Massachusetts Medical School s Center for Health Policy and Research is dedicated to research, evaluation, and education initiatives that advance public health policy and outcomes worldwide. As part of a leading academic health sciences center, our high-quality, insightful research shapes public policy, from the bedside to the community. Improving access to culturally and linguistically responsive health care is the top priority of the MassAHEC Network, a statewide system that is part of Center for Health Policy and Research and part of a national network of Area Health Education Centers. For more information on this report, please contact Table of Contents l 1

3 Executive Summary As part of the Commonwealth s overall effort at health care reform, Chapter 305 of the MA Acts of 2008 included several provisions regarding end of life care. Specifically, Section 41 of Chapter 305 mandated the convening of an expert panel on end of life care to: investigate and study health care delivery for patients with serious chronic illness and variations in delivery of care among health care providers in MA; identify best practices for end of life care, including those that minimize disparities; and present recommendations for any legislative, regulatory, or other policy changes necessary to implement its recommendations. (M.G.L. Chapter 305 of the Acts of 2008, Section 41) In 2010, a panel of forty-three Massachusetts end of life and palliative care experts and advocates produced the Massachusetts Expert Panel on End of Life Care Report Patient-Centered Care and Human Mortality: The Urgency of Health System Reforms to Ensure Respect for Patients Wishes and Accountability for Excellence in Care. (See Panel Report: Section 103 of Chapter 224 of the Acts of 2012 continued the focus to improve care at the end of life. In 2014 the MA Department of Public Health (DPH) requested that Commonwealth Medicine at the University of Massachusetts Medical School update the 2010 Expert Panel Report and re-establish priorities for end of life care Report Recommendations The 2010 Report issued six major recommendations to address deficiencies and inconsistencies in end of life care identified in Massachusetts: 1. Inform and Empower Residents of Massachusetts. 2. Support a Health Care System that Ensures High Quality Patient-Centered Care. 3. Ensure a Knowledgeable, Competent, and Compassionate Workforce. 4. Create Financing Structures that Promote Patient-Centered Care. 5. Create a Responsible Entity to Ensure Excellence and Accountability. 6. Employ Quality Indicators and Performance Measurement Report Update To update the report, the following approach was implemented: 1. Conduct a brief survey among MA end of life and palliative care experts regarding the status of the six major recommendations in the 2010 Report. 2. Conduct key informant interviews with a smaller group of end of life and palliative care experts regarding the 2010 recommendations. 3. Use findings from the survey and interviews to inform a discussion for creating an action plan at the 2014 MA End of Life Summit held on April 9, Submit to MA DPH an updated report incorporating findings from these activities and a suggested action plan. This report provides a brief snapshot of end of life care activity in Massachusetts since the 2010 report, identifies related themes and trends in MA health care institutions, and conveys current concerns and priorities for improving end of life care in the Commonwealth. Executive Summary l 2

4 2014 Plan for Action An action plan was developed for each of the 2010 recommendations. To summarize, the action plan for: Recommendation 1 seeks to secure organizational and funding resources as soon as possible to develop and implement a public awareness campaign in MA about advance care planning, palliative care, and end of life options. Recommendation 2 seeks to ensure that patients are engaged in advance care planning, and that health care professionals have access to tools and processes that will prepare them to communicate competently and compassionately with patients in the health care setting. Recommendation 3 seeks to identify professional palliative care and end of life care educational resources in MA institutions; and to establish core competencies and build capacity and accountability for communication between patients, families, and health care providers. Recommendation 4 seeks to develop and disseminate among MA health care institutions and other stakeholders billing and financial system modifications to support and optimize patient-centered palliative care and end of life care in MA. Recommendation 5 seeks to create and secure funding for a recognized entity with broad stakeholder support responsible for ensuring excellence and accountability in palliative care and end of life care in MA. Recommendation 6 seeks to determine and define relevant measures for palliative care and end of life care in various clinical care settings, and to establish state benchmarks for high quality care. Next Steps It is crucial that the public become aware of available options for palliative care and end of life care as stated in Recommendation 1. Care and treatment decisions made by an informed and empowered public will result in greater concordance between the expressed preferences of patients and the care that is actually provided. This was identified as the highest priority by survey respondents. Steps toward ensuring improvements in end of life care in Massachusetts must be addressed interdependently. To accomplish this, a coordinating mechanism needs to be in place that has both the authority and the resources to promote implementation of the recommendations, disseminate best practices, and support efforts to measure performance improvements. Creating a responsible entity to ensure excellence and accountability is a matter of urgency because without it, the other recommendations are not likely to be successfully navigated and coordinated throughout the Commonwealth. For this reason, the implementation of Recommendation 5 deserves prompt attention, which will allow other improvements to follow. Executive Summary l 3

5 Introduction Background In 2008 the Massachusetts Legislature passed Chapter 305 of the Acts of 2008, which included several provisions regarding end of life care in the Commonwealth. Section 41 of Chapter 305 mandated the convening of an expert panel on end of life care to: Investigate and study health care delivery for patients with serious chronic illness and the variations in delivery of care among health care providers in MA; Identify best practices for end of life care, including those that minimize disparities; and Present recommendations for any legislative, regulatory, or other policy changes necessary to implement its recommendations. (M.G.L. Chapter 305 of the Acts of 2008, Section 41) To that end, a panel of forty-three Massachusetts end of life and palliative care experts and advocates met during The outcome of these efforts was the 2010 Massachusetts Expert Panel on End-of-Life Care Report Patient-Centered Care and Human Mortality: The Urgency of Health System Reforms to Ensure Respect for Patients Wishes and Accountability for Excellence in Care. (See Panel Report: The report issued six major recommendations and numerous specific steps to address deficiencies and inconsistencies in end of life care identified in Massachusetts. The recommendations included: Recommendation 1: Inform and Empower Residents of Massachusetts Recommendation 2: Support a Health Care System that Ensures High Quality Patient-Centered Care Recommendation 3: Ensure a Knowledgeable, Competent, and Compassionate Workforce Recommendation 4: Create Financing Structures that Promote Patient-Centered Care Recommendation 5: Create a Responsible Entity to Ensure Excellence and Accountability Recommendation 6: Employ Quality Indicators and Performance Measurement Concurrent with this effort, the Medical Orders for Life-Sustaining Treatment (MOLST) Demonstration Project, also mandated by Chapter 305 in Section 43, was conducted in the Greater Worcester area through collaboration among the MA Executive Office of Elder Affairs, the MA Department of Public Health (DPH), and Commonwealth Medicine at UMass Medical School. MOLST is a standardized medical order form for use by clinicians caring for patients with serious advancing illnesses. (See MOLST website: After a successful pilot, the MOLST Steering Committee recommended that MOLST be expanded throughout Massachusetts. (See MOLST Demonstration Report: The Expert Panel agreed with this conclusion, calling for state-wide expansion of MOLST by January 2014, which was achieved. Introduction l 4

6 Today s Imperative In early 2014, the MA DPH requested that Commonwealth Medicine update the 2010 Expert Panel Report and re-establish priorities for end of life care. The process used to accomplish this is described in Appendix B, and the results of those processes follow in Appendix C. The purpose of this report is to provide a brief snapshot of end of life activity in Massachusetts since the 2010 report, to identify related themes and trends in health care institutions, and to convey current concerns and priorities for improving end of life care in the Commonwealth. Improving end of life care in the age of health care reform in both Massachusetts and on the national front requires that careful consideration be given to several crucial factors: patient choice, patient engagement, quality, and cost. The 2010 Expert Panel Report has already pointed Massachusetts in this direction by issuing strong recommendations that address these factors. The importance of patient choice and patient engagement are acknowledged in Recommendation 1 by pointing out the need to hear the patient s voice regarding preferences for care at the end of life, and by issuing a mandate to ensure that those preferences are honored. Quality is addressed in Recommendations 2, 3, and 6 through prescribing changes in the Massachusetts health care system and in the education of competent and compassionate health care providers, and also by highlighting the need to monitor and measure the performance of health care institutions as they provide care to the sickest and most vulnerable of patients. Cost factors are emphasized in Recommendation 4, which proposes the creation of financing structures that promote patient-centered care; while in some cases this may mean that more medical treatment is provided, in many cases this will also mean that unwanted medical treatment is not provided. To ensure that the proposed end of life improvements occur in Massachusetts, these compelling recommendations must be addressed interdependently. To achieve this, a coordinating mechanism needs to be in place that will have both the authority and the resources to promote the implementation of these recommendations, disseminate best practices, and support efforts to measure performance improvements. Creating a responsible entity to ensure excellence and accountability is a matter of urgency because without it, the other recommendations are not likely to be successfully navigated and coordinated throughout the Commonwealth. For this reason, the implementation of Recommendation 5 deserves prompt attention. As members of the 2010 Expert Panel so compellingly state in their Report: Once the steps we recommend are implemented, we are convinced that when each of us confronts a serious advancing illness, and one day the inevitable fact of our own mortality, we and our loved ones can know that we will be cared for with the respect, the compassion, and the excellence that we will want, need, and deserve. Achieving this will require our united efforts. Introduction l 5

7 Massachusetts End of Life 2014 Summit Action Plan Update to: Recommendation 1 Inform and Empower Residents of Massachusetts, MA End of Life Expert Panel Report, 2010 I. Summary Statement Recommendation 1 should be achieved through the following initial steps: a. Establish an ongoing group to explore Recommendation 1. b. Secure organizational and financial resources as soon as possible, to develop and implement a Massachusetts public awareness campaign. c. As a practical initial step, catalogue state-wide efforts of MA health care providers to share ideas, program resources and best practices for educating patients, families and communities about advance care planning and other end of life issues. These resources can be considered for use when a public awareness campaign is supported with resources. d. Collaborate with the Recommendation 6 Work Group to develop measures of progress. II. Discussion a. This recommendation was ranked the highest priority of all the six major recommendations by responders to the March 2014 End Of Life Survey distributed to Massachusetts end of life experts and advocates before the End of Life Summit. b. Funding and the establishment of an institutional home for a Massachusetts advance care planning public awareness campaign were considered high priorities by Recommendation 1 Work Group participants, who expressed serious concern about conducting a sustained and significant campaign across the state without financial resources. The responsible entity proposed in Recommendation 5 of the MA End of Life Expert Panel Report could serve as the institutional home or, if funding were able to be achieved, an interested not-for-profit institution, or a collaboration of several institutions with a similar mission could serve in this role. Examples of entities which might be interested in funding an end of life public awareness campaign include Massachusetts health care insurers, accountable care organizations, and Massachusetts professional and trade associations. c. A statement of purpose for the campaign, as well as vision and mission statements, should be developed. d. Many members of the Recommendation 1 Work Group indicated that they would be willing to form an ongoing group to continue to explore Recommendation 1. Summit Action Plan l 6

9 Update to: Recommendation 2 Support a Health Care System that Ensures High-Quality, Patient-Centered Care, MA End of Life Expert Panel Report, 2010 I. Summary Statement Recommendation 2 should be achieved through the following initial steps: a. Ensure that patients are engaged in advance care planning by increasing general awareness of advance care planning tools within health care institutions. b. Develop tools and processes for practitioners and clinical teams to serve as triggers for engaging patients. c. Develop guidelines for how to communicate with patients and institutions in discharge planning. II. Discussion a. Discussed key factors for consideration: i. New MA end of life regulations, Chapter 224, Section 103. ii. Advance care planning (ACP) timeline across the lifespan. (See chart, page 9.) iii. The importance of appropriate timing; where/when ACP can be introduced safely. iv. Conversations should occur with transitions of care; follow the continuum of care model. v. Standard information should be provided on admission. vi. Sample models, resources and tools should be made available: how to engage the patient, triggers for health care providers, etc. b. Defined scope of ACP: 3 D s, i.e. directives, discussions, decisions (See chart, page 9.) c. Discussed components of good practices: i. Increase general awareness of ACP tools. ii. Provide information on basics; every patient should have ACP. iii. Identify and engage patients: Use trigger tools for when to engage in specific stages. iv. Use simple language. v. Develop processes for clinicians and core team, and use tools for each step. vi. Create guidelines for how to communicate in discharge planning and across the continuum. vii. Apply lessons learned from MOLST. viii. Need repository, like all the MOLST resources. Summit Action Plan l 8

11 Update to: Recommendation 3 Ensure a Knowledgeable, Competent and Compassionate Workforce, MA End of Life Expert Panel Report, 2010 I. Summary Statement Recommendation 3 should be achieved through the following initial steps: a. Convene a work group to complete an action plan for Recommendation 3. b. Gather information about what related training or education is currently being offered in schools, facilities, and communities. c. Identify baseline competencies for all disciplines. d. Develop starter kit (with video) as a training resource, and work with institutions to make it available. e. Build capacity for all disciplines to begin to discuss end of life, and accountability for all health professionals to participate in aspects of these conversations. f. Build capacity for clinicians to focus on prognostication. II. Discussion a. Work Group noted that workforce recommendations in the 2010 Report remain a priority. b. There may be different training needs for health care professionals who are community-based vs. those providing care in various clinical settings. c. There is good existing palliative care training that different institutions are currently using, although it s not known who is using what, and there s no consistency. We could establish a baseline training curriculum for core competencies but should not re-create the wheel. (Training already in use: End-of-Life Nursing Education Consortium or ELNEC, for nurses, and Education in Palliative and End of Life Care or EPEC, for physicians.) d. The process from the discussion of EOL care to the documentation of the discussion and its outcome can be challenging, including signing the MOLST form: How to get there? How to get the discussion going? How to have meaningful discussions and decision-making? e. Barriers: Time constraints; also, difficult to have this conversation due to anxiety. Need to establish first where the patient is. Medical culture is geared toward doing everything possible to make patients better. Prognostication is difficult. It s helpful to hear feedback from patients, palliative care specialists and families. f. Other points of discussion: i. Get feedback from families of patients who died about whether their preferences were met. Most people want to die at home but most die at the hospital. How do we change this, and ensure other preferences are honored? ii. Teach interviewer skills, one-liners to introduce the topic: Let s talk/think about what s most important to you; use palliative care doctors for modeling, teaching and mentoring. iii. Define pathways and develop process steps independent of roles and settings: How is discussion initiated? (Can be by multiple disciplines.) Who recognizes and communicates how serious the illness is? Who signs the MOLST form? What is the process for getting someone ready to communicate? Summit Action Plan l 10

12 Summit Action Plan: Recommendation 3 (Update continued) iv. Require MOLST training; educate providers that pain management is different at end of life; develop train the trainer models; use different approaches or providers in facilities, schools and communities. v. Consider Pri-Med as an educational tool, and look into the Accreditation Council for Graduate Medical Education milestones (curriculum being developed). vi. Leverage MA Board of Registration in Medicine Continuing Medical Education requirements for EOL and pain management; find out if palliative care has been included in Board of Nursing regulations. III. Key Milestones a. Assess/survey who is providing training in Massachusetts (schools and health care institutions). b. Determine what core competencies in palliative care every health care professional should have. c. Establish a baseline training curriculum for core competencies. Summit Action Plan l 11

13 Update to: Recommendation 4 Create Financing Structures That Promote Patient-Centered Care, MA End of Life Expert Panel Report, 2010 I. Summary Statement Recommendation 4 should be achieved through the following initial steps: a. Revise/update advance care planning (ACP) billing codes for all disciplines across all settings. b. Revise/update palliative care billing codes for all disciplines across all settings. c. Reconvene work group. II. Discussion a. There was general agreement about: i. The urgency of removing barriers in order to provide incentives and financing structures to promote patient-centered care. ii. ACP discussions should occur earlier in disease process to help document and communicate patient goals of care and personal quality of life and EOL care preferences. b. Distributed a brief outline of programs in place or in pilot to address Recommendation 4 which included the following: i. Basic and MassHealth Plans now include hospice coverage, as recommended by the EOL Expert Panel, effective July (Except in skilled nursing facilities.) ii. CMS ongoing pilot ( ) in place to evaluate cost/quality outcomes while addressing current shortcomings (Reduced hospice length of service), through provision of Medicare Hospice Benefit coverage concurrently with active cure-oriented therapies. c. Group members discussed existing billing code shortcomings for ACP/goals of care discussions, palliative care services billing codes and hospice reimbursement structure; agreed to focus efforts on addressing billing code deficiencies as the initial undertaking. Financial incentives are needed for: i. Procedure codes for goals of care values discussion (most important priority for Recommendation 4); these codes could be used by multiple providers: primary care provider, hospitalist, specialist, clinicians in all settings skilled nursing facilities, long term care. ii. Reimbursement, whether money-wise or Relative Value Unit (RVU)-wise; sets up for quality measures to know how many conversations occur (i.e. when billing, look at documentation). d. Other discussion: i. Re-analyze hospice/concurrent care reimbursement models. ii. Financial incentives for education in palliative care clinicians, aides, etc. skilled nursing facilities, long term acute care, etc. for people providing direct care. iii. Pay for performance measures that every patient in MA should have a health care agent name in the record 100%. Summit Action Plan l 12

15 Update to: Recommendation 5 Create a Responsible Entity to Ensure Excellence and Accountability, MA End of Life Expert Panel Report, 2010 I. Summary Statement Recommendation 5 should be achieved through the following initial steps: a. Create an entity, possibly an independent 501(c) (3), with broad stakeholder support and representation for governance. b. Secure sustainability funding (including seed funding) from the Commonwealth, to create this membership organization. c. Provide governance by a community board with broad group of stakeholders, and staffed by content experts. d. Identify and promulgate metrics and best practices for palliative/end of life care. e. Report out progress on defined goals. II. Discussion a. Recommendation 5 Work Group agreed that there needs to be a responsible entity but not a legislative commission, (although it could continue some of the earlier work done by the MA Commission on End of Life Care). b. Scope needs to be broader, starting upstream and focusing much earlier with patients. c. Should keep focused on patient empowerment/choices although the name Honoring Choices is taken, something similar that conveys this concern would be suitable. d. What kind of entity? Independent, not-for-profit (501(c)3); academic institution; Betsy Lehman Center and MA Coalition for Prevention of Medical Errors could serve as models. e. American Cancer Society Quality of life: H. 2104, currently before the MA Legislature. III. Key Milestones a. Convene a Steering Committee to explore the feasibility of creating a responsible entity to implement and monitor Expert Panel recommendations. b. Secure seed funding, for initial phase of planning and development. c. Determine governance and staffing structure and other needed resources. Summit Action Plan l 14

16 Update to: Recommendation 6 Employ Quality Indicators and Performance Measurement, MA End of Life Expert Panel Report, 2010 I. Summary Statement Recommendation 6 should be achieved through the following initial steps: a. Determine which data are relevant, accessible, and provide good quality measures for palliative and end of life care in MA. b. Partner with national and state organizations and agencies to create a framework for measuring quality of end of life and palliative care in MA. c. Establish state benchmarks for measuring palliative and end of life care in various MA health care settings. II. Discussion a. Among the work group members was a wealth of clinical, academic, and administrative experience. b. The group agreed that we are just beginning in this area even at the End of Life Summit meeting, there was almost no data. It is essential to have accurate quality data for palliative and EOL care, and we need to collect a variety of different types of quality measures and data. III. Key Milestones Define the data we want to collect. Steps include: a. What: Partner with American Academy of Hospice and Palliative Medicine Quality and Practice Standards Taskforce; partner with National Hospice and Palliative Care Organization and American Society of Clinical Oncology campaign: Measuring what Matters (looking at existing National Quality Forum measures and hospices measures, trying to determine the 10 most valuable EOL measures, using researchers and clinicians) rather than re-invent the wheel. Consider state benchmark for hospice and palliative medicine groups. i. How: There are monthly phone meetings; bring relevant data back. ii. With what: Ethical; Compliance, Governance and Oversight Council; patient/family. iii. Comments: Includes patient/family experience; global; physical aspects of care; structure/process; psychological; spiritual; utilization. b. What: Partner with Center for Health Information and Analysis to look at utilization data in last two years of life; get MA-specific data, maybe by county. i. How: Talk with researchers involved. ii. Comments: This will show variations across the state. Summit Action Plan l 15

18 Recommended Next Steps Based on the input from the EOL Summit Work Group participants (see pages 6-16 for a summary of each Summit Work Group discussion and recommendations for action), we propose the following next steps. It is worth noting that survey participants ranked the need for an End of Life Public Awareness Campaign (Recommendation 1) as the highest priority. (See Appendix C.) However, without a responsible entity to coordinate and move the EOL agenda in Massachusetts forward, as proposed in Recommendation 5, the work of other recommendations will be difficult to accomplish. For this reason, determining the feasibility of creating such an entity is accorded a high priority. Several of the work groups (Recommendations 1, 4, and 6 Work Groups) have already begun to work on their action plan. Steps Rec 1: Public Awareness Rec 2: Health Care System Rec 3: Workforce Rec 4: Finance Structures Rec 5: Responsible Entity Rec 6: Quality & Performance 1 - Establish work group; develop work plan. - Identify institutional home for EOL Public Awareness Campaign. - Build coalition of stakeholders. - Establish work group; develop work plan. - Establish work group; develop work plan. - Assess/survey who is providing training in MA schools and health care institutions. - Establish work group; develop work plan. - Review existing palliative care codes in other states, Canada. - Convene steering committee to determine feasibility. - Establish work group; develop work plan. - Partner with national organizations (AAHPM, NHPCO, etc.) to determine most valuable EOL measures. RE-CONVENE SUMMIT 2 - Identify funding sources for PAC. - First stakeholder meeting. - Catalogue current EOL educational efforts in MA. - Develop guidelines to identify patients who need to have ACP conversation or information. - Determine core competencies in palliative care that all health care professionals should have. - Develop 1-page statement for procedure billing codes. - Determine governance, staffing, budget and other resources needed. - Investigate Behavioral Risk Factor Surveillance System in MA: Possible to adapt survey to capture data for Recommendation Second stakeholder meeting. - Develop plan for National Healthcare Decisions Day, April Determine tools already in use; form alliances with ACP programs. - Establish baseline training curriculum for core competencies. - Contact larger MA & OTHER entities (MMS, CMS / ACPE, MAHP); deliver 1-page statement to stakeholders. - Secure seed funding, planning and development. RE-CONVENE SUMMIT 4 - Third stakeholder meeting. Develop plans for: - Partnering with CHIA to look at utilization data in last 2 years of life. - Feasibility of e-registry for ACP for MA residents. Recommended Next Steps l 17

20 Appendix B: Description of Process to Update 2010 Expert Panel Report In 2014, the MA Department of Public Health requested that Commonwealth Medicine review and update the recommendations for improving end of life care as set forth in the 2010 Expert Panel Report, and to re-establish MA end of life/palliative care priorities. The following approach was developed: 1. Conduct a brief survey among MA end of life (EOL) and palliative care (PC) experts regarding the six major recommendations in the 2010 Expert Panel Report. 2. Conduct key informant interviews with a smaller group of end of life and PC experts regarding the 2010 recommendations. 3. Use findings from the survey and interviews to inform a discussion for creating an action plan at the MA End of Life Summit to be held on April 9th. 4. Submit to MA DPH an updated report incorporating findings from these activities and a suggested action plan. End of Life Survey A brief online survey was sent in March 2014 over a two-week period to 91 MA end of life/palliative care experts and advocates, including members of the former expert panel as well as other current leaders across the state. Names of invitees were provided by the Expert Panel leadership, the MA Department of Public Health, and the Medical Orders for Life-Sustaining Treatment Steering Committee. Participants were told that the results would be reported in the aggregate. Of the 91 persons invited to respond, 47 (52%) completed the survey. All regions of MA were represented. Each recommendation from the Expert Panel Report was summarized in the survey, and a link was provided to the full report for reference as needed. The following instructions were given for each recommendation: Please briefly describe any new initiatives or improvements in end of life care that you are aware of or are participating in. In your opinion what remains a priority for this recommendation in MA? Respondents were also asked to rank recommendations 1 through 6 in order of priority for end of life work that remains to be done in MA, and were given an opportunity to comment on other EOL/PC priorities not included in the original report. Key Informant Interviews Seventeen additional EOL/PC experts and advocates were contacted during March and invited to participate in interviews conducted by two members of the earlier Expert Panel. Sixteen people responded and agreed to participate. One person later requested not to have his/her comments included in the final report. Participants were asked about any updates or new activities or programs in EOL/PC in MA they were aware of, and were asked to rate the relevancy and urgency of the 2010 recommendations today. The interviews lasted from approximately 30 minutes to 75 minutes, thus allowing more time for the respondent to elaborate on answers about current MA EOL/PC activities and priorities. All regions of MA were represented. Appendix B l 19

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